UNITED STATES COURT OF APPEALS
FOR THE TENTH CIRCUIT
Case No. (A -FOS SS
Plaintiff/Petitioner - Appellant, ‘Motion for Leave to Proceed
‘on Appeal Without
vy Prepayment of Costs or Fees
(non-PLRA)
Defendant/Respondent -
Appellee.
bs” foe ko Sy Y
captioned case move this court for leave to proceed in forma pauperis.
the petitioner/appellant in the
In support of this motion, I state that because of my poverty, I am unable to pay the
costs of said proceedings or give security therefor, I submit the following financial
declaration.FINANCIAL DECLARATION
Affidavit to Accompany Motion for Permission to Appeal in Forma Pauperis
I swear or affirm under penalty of perjury that because of my poverty I am unable to pay the docket
fees of my appeal or to post a bond for them. I believe | am entitled to a different result than that
reached in the district court.
| further swear or affirm under penalty of perjury that the responses which I have made to the
questions and instructions below relating to my ability to pay the fees for my appeal are true.
Instructions. Please complete all questions in this application and then sign it on the last
page. If the answer to any question is "0" or "none," of the question is "not applicable”, so
indicate by writing "0", "none", or "not applicable (N/A)". If additional space is needed to answer
any question or to explain your answer to any question, please use and attach a separate sheet of
paper identified with your name, the docket number of your case and the number of the question.
My issues on appeal are:
[LE THE "dew EviDence suOmiTAD To me Distter Cue
Cousrinumed Lega Respousieuuty Foe THE Caw TO
RELIEVE ~Jo ae AND OFFICULLY SERVE AND SIQN THE
ORDER TO SHou) Case.
a To upland He Us. Cousmryrrais Sumrigrous FOR THE
FoR TO my.
ite a MO aa
And
A Peesioenmt al
1. Are you or your spouse currently employed? Yes &_—No
2. Ifyou or your spouse are currently employed, state the name and address of your employer,
the length of your employment with that employer, and your monthly gross pay. Gross pay is
pay before any taxes or other deductions are taken. If you have more than one employer,
please provide the information requested below about the other employer(s) on a separate
sheet of papey and attach it to this application.
Youselt: f 1,200. /raD. — VourSpouse: AYA
‘A-I4 Motion for Leave to Proceed on Appeal without Prepayment of Costs or Fees (Non-PLRA) 12/13
Page 2‘Name and Address of Employer
‘Name and Address of Employer
Length of Employment
Years “Months
2
Monthly Gross Pay $4 2Q2° Monthly Gross Pay $. We
3. Ifyou are currently unemployed, state the date of your last employment and your monthly
‘gross pay during your last month of employment. Gross pay is pay before any taxes or other
deductions are taken.
to show the monthly rate.
Did-you receive money from
any of the following sources
during the past 12 months?
Self-employment
Income from real property
(uch as rental income)
Interest and dividends
Gifts
Alimony
Length of Epler
Aye lonths
Date of last employment (Month/Year) for yourself As } spouse U-
Monthly gross pay during last month of employment $
4, State whether you or your spouse have received money from any of the following sources
during the past twelve months, and, if so, the average monthly amount from that source.
‘Adjust any money that was received weekly, bi-weekly, quarterly, semi-annually, or annually
Average monthly amount during Amount expected next
past 12 months for you and your month
spouse if applicable.
Spouse
You a
On sags
Ot s.Q os
yal sO s
YIN__ s 700°” s
YO sO s_' s_oO s___
‘A-14 Motion for Leave to Proceed on Appeal without Prepayment of Costs or Fees (Non-PLRA) 12/13
Page 3Child Support YON sO s fa st s_ AA
Retirement income from sources such
as social security, private pensions,
annuities, or insurance policies
Disability payments such as social
yOu s_o_ sulk s_O saa.
security, other state or federal
government, or insurance payments YAN $_Q $_N& s_O_ $s
Unemployment payments Yon s_O_ $ s_O_ $s
Public assistance payments such as
welfare payments yOu. s_O snk s_O s
Other sources of money,
(specify: DONT Why PREM) OQM. sssd_s s_1s0 s_nlA
TOTAL A 4,350 s_® $1360." s_ WA.
0
5. State the amount of eash you and $d bpeise have: $_5O
‘State below any money you or your spouse have in savings, checking, or other accounts in a bank
or other financial institution.
Bank or Other Financial Institution: Type of Account Amount you Amount your
such as savings, have: spouse has:
_ Pecks or CD: : 0 : /
= = s_> s_fa
$ 4
Ifyou are a prisoner seeking to appeal a judgment in a civil action or proceeding, you must
attach a statement certified by the appropriate institutional officer showing all receipts,
expenditures, and balances during the last six months in your institutional accounts. If you
have multiple accounts, perhaps because you have been in multiple institutions, attach one
certified statement of each account.
= i
‘A:14 Motion for Leave to Proceed on Appeal without Prepayment of Costs or Fees (Non-PLRA) 12/13
Page 46. State below the assets owned by you and your spouse, Do not list ordinary household
furnishings and clothing.
Home Address: Value: $ ot
Nj Amount owed on mortgages and
$
liens:
Other real Address: Value: $ 7
estate wf Amount 01 on mortgages and
liens: $
Motor vehicle Model/Year: Value: $
Amount owed: $
Motor vehicle Model/Year: Value: $
— yh Amount owed: $ af
Other Descriptio Value: $
cd
(See FREE Ne oe 0
7. State below any person, business, organization, or governmental unit that owes you or your
spouse money and the amount that is owed.
Name of Person, Business, or Organization Amount Owed Amount Owed
that Owes You or Your Spouse Money You ‘Your Sppuse:
— §$
SS ee lg
oA so. s_y
A-14 Motion for Leave to Proceed on Appeal without Prepayment of Costs or Fees (Non-PLRA) 12/13
Page 58. State the individuals who rely on you and yr shgise for support. Indicate their relationship
to you, their age, and whether they live with you.
Name Relationship Does this person live with
you?
coon) 7 Yes X No.
: _ Yes No
_ Yes No
Yes No.
9. Complete this question by estimating the average monthly expenses of you and your family.
Show separately the amounts paid by your spouse. Adjust any payments that are made
weekly, bi-weekly, quarterly, semi-annually, or annually to show the monthly rate.
You Spouse
0
Lor home mortgage payment (include lot rented for mobile S450" $ MA
rome)
Are real estate taxes included? Yes x No
Is property insurance included? Yes No XK .
Utilit Electricity and heating fuel s_ s0°
Water and sewer sO
Telephone s_j20"”
other Toumeeaig 3.30"
Home maintenance (Repairs and upkeep) s_s
Food Stoo”
Clothing s_lo”
Laundry and dry cleaning _
Medical and dental expenses
|A-14- Motion for Leave to Proceed on Appeal without Prepayment of Costs or Fees (Non-PLRAA) 12/13,
Page 6‘Transportation (not including car payments)
Recreation, clubs and entertainment, newspapers, magazines, etc,
Charitable contributions
Insurance (not deducted from wages or included in home
‘mortgage payments)
‘Homeowner's or renter’s
Life
Health
Auto
Other
‘Taxes (not deducted from wages or included in home mortgage
payments) (specify) Oo _
Installment payments
Auto: RetRTRA On
Credit Card: (name)
Department Store: (name) * fA _
Other
Other
Alimony, maintenance, and support paid to others
Payments for support of additional dependents not Ii
home
Regular expenses from operation of business, profession, or farm
(attach detailed statement) BY MERT TO SELL
Other
ing at your
TOTAL MONTHLY EXPENSES
A-14 Motion for Leave to Proceed on Appeal without Prepayment of Costs or Fees (Non-PLRA) 12/13
Page 710. Do you expect any major changes to your monthly income or expenses or in your assets or
liabilities during the next 12 months? Yes No
If yes, describe on an attached sheet.
11, Have you spent- or will you be spending- any money for expenses or attomeys fees in
connection with this case? Yes ‘No
Ifyes, how much? $ -N\er
tyes, provide the name, address, and telephone number of the attorney:
i
12. Have you promised to pay or do you anticipate paying anyone other than an attorney (such
as a paralegal, typing service, or another person) any money for services in connection with
this case, including the completion of this form? Yes__ No
Ifyes, how much? $
Ifyes, [ar the name, address, and telephone number of the person or service:
13, How much can you pay each month toward the docket fee for your appeal:
s ~
14, Please provide any other information that helps to explain why you cannot pay the
docket fees for your appeal. j- WANE NO ANAIKGLE WOME
‘A+I4 Motion for Leave to Proceed on Appeal without Prepayment of Costs or Fees (Non-PLRA) 12/13
Page 815. State the city and state of your legal residence: Ont, UTA, Urey
Your daytime phone number:
Your age:
Years of schooling: _\\g
[Last four digits of] your social security number a
IDECLARE UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE UNITED
STATES OF AMERICA THAT THE FOREGOING IS TRUE AND CORRECT. 28 U.S.C. §
1746, 18 U.S.C. § 1621,
Date: 4- QY- 20/4 Signature:
‘Acl4- Motion for Leave to Proceed on Appeal without Prepayment of Costs or Fees (Non-PLRA) 12/13
Page 9CERTIFICATE OF SERVICE
Thereby certify that on farfacre I sent a copy of
ate]
the foregoing Motion for Leave to Proceed on Appeal without Prepayment of
,at_eputle Besraassr he, Ko caw,
Lstdjron) 200009 € dat. 4130 So. Capit St SE
lbecanncgml YO, fons —____ tre as known
address/email address, by
Costs of Fees, to:
[state method of service]
ye AG
Sriges Coer or Appens
ee Team Ceeut-
Opec oF THe Quark
By Ron) Ijin Unired Srares Guertouse
1223 SrouT Srekeet—
Dewer, CO, 20254
‘A+14 Motion for Leave to Proceed on Appeal without Prepayment of Costs or Fees (Non-PLRA) 12/13
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